Nicotine replacement therapy for a healthier nation

Nictotine replacement is cost effective and should be prescribable on the NHS

News p 1271

The aims of the British government's health policy are to improve the health of the population as a whole and to reduce health inequalities.1 Specific reductions in mortality in four areas (cardiovascular disease, cancer, accidents, and mental health) are set as targets. In the search for specific action to meet these targets helping people to stop smoking would seem to be an obvious candidate.

The World Health Organisation has identified smoking as the single most important preventable cause of death in Europe.2 Cigarette smoking is a major cause of morbidity and mortality in two of the government's target areas: cardiovascular disease and cancer.1 Evidence continues to accrue of a contributory role for smoking in a range of other diseases, such as fractures of the hip due to reduced bone mineral density. The adverse health effects of smoking are not restricted to the smoker. Passive smoking causes lung cancer, ischaemic heart disease, sudden infant death syndrome, and middle ear disease and respiratory illness in children.3

Smoking increases socioeconomic health inequalities in two ways. Higher rates of smoking among those with the lowest incomes mean that the burden of disease due to smoking is highest in these groups.4 In 1991 adults in three quarters of the families receiving income support smoked, and one seventh of their disposable income was spent on cigarettes.4 By exacerbating the poverty of those on the lowest incomes, the health effects of smoking go way beyond the direct effects of tobacco fumes.5

Stopping smoking is difficult. Although the effect of giving advice in encouraging cessation is small, if widely undertaken such advice would lead to considerable public health gains.6 The use of nicotine replacement therapy produces much higher rates of stopping. A systematic review of 47 trials including over 23 000 patients showed that nicotine replacement therapy doubled smoking cessation rates when compared to placebo, with follow up periods of 6-12 months.7 The effect was consistent across a range of settings, from specialised clinics to brief interventions in primary care. The effectiveness of the different preparations (transdermal nicotine patch, nicotine gum, intranasal nicotine spray, and inhaled nicotine) is broadly similar, although there have only been a few small trials of the nasal spray and inhaled preparations, none of which were in primary care. Few health interventions have such overwhelming evidence of effectiveness. Yet nicotine replacement therapy is not available on prescription in the NHS.

Cost is clearly one possible barrier to making nicotine replacement therapy prescribable. When making comparisons with other interventions it is important to remember that smoking cessation therapy is an episodic, not a lifelong, treatment. Therefore, despite a large number needed to treat to prevent one death, when benefits are expressed as cost per life year saved nicotine replacement therapy is cost effective compared with other interventions. 8 9 Smoking cessation after one week of therapy is a good predictor of sustained cessation and could be used as a means of limiting the continuation of the intervention to those patients most likely to be helped.10 Costs to the health service must be balanced against costs to the individuals who are currently denied access to a highly effective health intervention.

So long as nicotine replacement therapy is not available on prescription its high retail price will remain prohibitive to many, particularly to people on the lowest incomes. If it were prescribable the current exemption categories from prescription charges would effectively target nicotine replacement therapy at the most socioeconomically disadvantaged groups.

Helping people to stop smoking is not a panacea. Socioeconomic differentials in health are due to many factors, of which smoking is only one.11 After stopping smoking the risks of different diseases fall at different rates. Ex-smokers remain at greater risk for some diseases than people who have never smoked, even many years after stopping.12 Reducing the numbers of people who take up smoking in the first place thus remains the most important aim of health policy on tobacco. Nevertheless, making nicotine replacement therapy available on prescription would be an effective way of working towards the aims of Our Healthier Nation.

GF has chaired an expert panel on smoking cessation, calling for a more effective UK policy on smoking cessation and the use of nicotine replacement, which was supported by Novartis.